Journal of Management in Medicine

Emerald Article: Problems in the delivery of medical care to the frail elderly inthe community Gillian Craig

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To cite this document: Gillian Craig, (1995),"Problems in the delivery of medical care to the frail elderly inthe community", Journal of Management in Medicine, Vol. 9 Iss: 2 pp. 30 - 33 Permanent link to this document: http://dx.doi.org/10.1108/02689239510086515 Downloaded on: 06-05-2012 References: This document contains references to 14 other documents Citations: This document has been cited by 1 other documents To copy this document: permissions@emeraldinsight.com This document has been downloaded 842 times.

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Journal of Management in Medicine 9,2 30

Problems in the delivery of medical care to the frail elderly in the community
Gillian Craig
Retired Consultant Geriatrician
Introduction A great many hospital long-stay wards for the elderly have closed in the last few years, and their frail occupants have been discharged to nursing homes or residential homes in the community, where their medical care becomes the responsibility of their general practitioner (GP), rather than a consultant geriatrician or psychogeriatrician. By 1990, there were over 300,000 residential home places, and over 100,000 nursing home places in the UK[1]. In addition, many frail elderly people remained in their own homes with intensive support from the district nursing service and social services. In April 1993, the Community Care Act was implemented and local authority social service departments became responsible for the assessment of elderly people for residential and nursing care, and for the allocation of funds to those who qualified for financial support. Each local authority attempted to tailor its service to the limited funds available. Within a year, many community care budgets were overstretched. Services were cut and voluntary organizations expressed grave concern[2,3]. There were adverse effects on hospital services where old people who could not be discharged safely remained in beds that were needed for acutely ill patients of all ages. The changing role of geriatric medicine As a consequence of the closure of long-stay wards, the specialty of geriatric medicine has been changed fundamentally. Many hospital departments now concentrate on acute medicine for the elderly, and on short-term rehabilitation, and consultant geriatricians are no longer involved in the long-term supervision of patients who need sensitive, but not intensive medical and nursing support. Cut off from this facet of their work, some consultants and their teams have experienced a sense of bereavement. Not only have the bonds between doctor and patient been broken, but skilled caring teams have been disbanded, sometimes at very short notice, in order to balance some departmental budget. As more and more frail elderly are cared for in the community, a mismatch of skills and patients has developed, since the majority of experienced doctors with geriatric expertise remain hospital based. Existing time-honoured work and referral patterns within the NHS will need to be modified to solve this problem. This will not be easy to achieve. Existing time-honoured work and referral patterns within the medical profession dictate that a consultant can only become involved in patient care at

Journal of Management in Medicine, Vol. 9 No. 2, 1995, pp. 30-33. MCB University Press, 0268-9235

the request of a general practitioner, except in an emergency, when a patient may be admitted via an accident and emergency department. After formal discharge, a new referral must be made. GPs in the UK guard their referral rights jealously, and resent any suggestion that it might be in the patients interest to enable other professionals to refer patients to a consultant[4,5]. Under most circumstances, the referral system works well, but from time to time, a patient who might benefit from a consultant opinion is deprived of one. Some GPs consider it important to protect their patients from hospital medicine[6], which is sad, since all consultants will know of patients who have been referred too late with eminently treatable diseases. There are times when from the consultant geriatricians viewpoint the hospital/community interface is like a wall, or a hostile frontier, that you cross at your peril. Somehow, movement of medical skills outwards from the hospital service must be made easier, for the benefit of patients who find themselves on the wrong side of the frontier. It is one thing to protect your elderly patient from hospital admission, which may be fatally distressing for them. It is another to deprive your patient of the help that can come from a skilled consultation. Conflict of integration of primary and secondary care The NHS management executive talks about the integration of primary and secondary care into one seamless whole. This concept overlooks the structural divide within the medical profession. The only way to have a seamless service is to allow free movement of professionals throughout the service. This could be achieved by much greater use of the domiciliary consultation service, by greater use of outpatient services, and by the employment of consultant geriatricians with amply sufficient sessions devoted to work in the community. The concept of a community geriatrician, though admirable, and well presented in an editorial in the British Medical Journal [7], has received little support[4,8], and very few posts have been advertised in recent years. However, if the care of patients in residential and nursing homes is to be improved, the profession must not allow the vested interests of sections of the profession to work against the interests of patients. The British Medical Association (BMA) recognize that the role of consultants in geriatric medicine in the delivery of community care needs attention and have called for more consultants to do outreach work in the community[9]. They recognize that the increase in the number of elderly and disabled people living in the community has major work-load implications for GPs. Although many GPs provide an excellent service to residential and nursing homes, others resent being involved. The problem can be particularly acute for single-handed rural GPs with one or more nursing homes in their area. Rural home managers faced with an unhelpful GP may find it difficult to make alternative arrangements for their residents. They may be discouraged from making a formal complaint for fear of reprisals, being dependent on the goodwill of doctors for their livelihood. Situations such as this could be improved if there was ready access to an alternative source of medical advice. Single-handed or otherwise, overburdened GPs could be supported by colleagues linked to the hospital service, who would share responsibility for the

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elderly nursing home residents. Even a regular monthly visit from a consultant might prove very helpful. NHS responsibilities Guidelines issued by the NHS executive in August 1994[10] (and finalized in February 1995) state that the NHS remains responsible for meeting, within available resources, the needs of people who require long-term physical or mental health care. Such care may include, where appropriate, specialist healthcare support, including specialist rehabilitative and palliative care to people in residential care homes or nursing homes in the community. It is time that the mechanism for delivery of such specialist support was put in place. There are grounds for concern that many residents in residential and nursing homes are not receiving appropriate medical and nursing care. District nurses report that elderly patients are often inappropriately placed, and some are neglected[11]. Hard-pressed district nurses tend to give priority to individuals living in their own homes, and much nursing is undertaken by the staff of residential homes, who may not be qualified to do this work. The Royal College of Nursing has called for trained inspectors to visit residential homes[11]. From time to time, scandalous deficiencies come to light, but little is done to improve the situation nationally[12]. Regrettably the staff of residential and nursing homes do not always get the support, leadership and guidance that they need from the medical profession[12,13]. The BMA have stated that the responsibility for providing medical care to people in residential and nursing homes should be reassessed[9]. They point out that the assumption that GPs will automatically be responsible is being increasingly challenged by the profession[9]. Many patients in nursing homes require a level of care and frequency of visits that is beyond that generally provided by GPs. Many GPs have no special expertise in geriatric medicine, and few hold the Diploma in Geriatric Medicine. Experience in geriatrics is still not obligatory during a GPs training yet GPs are now responsible for the supervision of most of the vulnerable and frail elderly in the community. The care of the mentally ill in the community is in some respects more advanced than that of the frail elderly. In order to qualify for a specific government grant, people with serious mental illness must be under the care of a consultant psychiatrist in the community, and at least one district has had the foresight to appoint a professor of community psychiatry. No such safeguards exist for the frail elderly who are discharged from hospital care. Could it be that they are not so visible and troublesome to the public as psychiatrically disturbed individuals who wander the streets of our cities? A bedridden quiet old person with a stroke can rapidly become invisible to the public conscience, and is unlikely to do anyone any harm. This does not mean, however, that society should overlook their needs, and the support of their carers. Attempts are being made, rather tentatively, in a few areas to bring the skills of the hospital-based geriatric team out into the community, but in general much more needs to be done to improve the situation. It would make sense to encourage consultant geriatricians to be more involved outside hospitals, yet

the British Geriatric Society is ambivalent, and supports the concept of community geriatricians, only if they operate from a strong hospital base. The BMA express concern about the status quo, but are resistant to change. Their community care committee is not in favour of the appointment of community geriatricians, and favours more training of GPs instead[14]. It is not clear what steps have been taken to bring this about. There is general agreement on the need for more co-operation between GPs and consultants in the care of the elderly[14]. In conclusion It all comes back to the problem of relationships between hospital doctors and those based in the community. Unless long-standing work patterns can be changed, the care of the frail elderly in residential and nursing homes will not improve. It is time to end restrictive practices within the profession, and to build bridges over the barriers between us, to enable the skills of the hospital-based, consultant-led geriatric medicine team to be brought to patients in the community. Failing this, local authorities and the private sector should appoint their own experienced and qualified geriatricians to work in the community, and liaise with NHS personnel as necessary. Without goodwill, and a willingness to try new work patterns, there never will be a seamless integration of primary and secondary care. The medical profession and their patients will be the losers.
References l. Henwood, M., Through a Glass Darkly, Community Care and Elderly People, Kings Fund Institute, London, 1992, p. 30. 2. James, E., New care cuts spark warning, The Citizen, 13 October 1994. 3. Etherington, S., Letter to The Guardian, 11 October 1994. 4. Heath, I. and Styles, W., Letter to British Medical Journal, Vol. 309, 1994, pp. 127-8. 5. Sweeney, B., The referral system, Editorial, British Medical Journal, Vol. 309, 1994, pp. 1180-1. 6. Tate, P., quoted by Logan, A., British Medical Journal, Vol. 310, 1995, p. 69. 7. Morris, J., The case for the community geriatrician, Editorial, British Medical Journal, Vol. 308, 1994, p. 1184. 8. Ebrahim, S., Denham, M. and Ritch, A., Letters to British Medical Journal, Vol. 309, 1994, p. 127. 9. Priorities for community care, British Medical Association Report, May 1992. 10. NHS responsibilities for meeting long term health care needs, NHS Executive draft guidelines HSG(94), Department of Health, Leeds, August 1994. Final version HSG, (95)8, February 1995. Also issued by the Welsh office, reference WHC (95)7 WOC 16/95. 11. A scandal waiting to happen? Elderly people and nursing care in residential and nursing homes, Royal College of Nursing, London, 1992. 12. Millard, P., Geriatric medicine beyond the hospital, Age and Ageing, Vol. 18, 1989, pp. 1-3. 13. Bowman, C., The medical vacuum in long-term care, Geriatric Medicine, Vol. 21, 1991, pp. 41-4. 14. BMA Community Care Committee, personal communication, 1993. (All correspondence about this article should be addressed to Dr Gillian Craig, 118 Cedar Road East, Abington, Northampton NN3 2JF.)

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